A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?
A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus.
A client who is 3 days postpartum and has not had a bowel movement since prior to admission.
A client who is 4 days postpartum and has lochia serosa.
A client who is 1 day postpartum and has not voided in 8 hr.
The Correct Answer is D
A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.
Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.
The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.
Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.
Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.
The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.
Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.
Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.
It consists of old blood, serum, leukocytes, and tissue debris.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Blood glucose 130 mg/dL.
This is because the normal range of blood glucose for pregnant women is 70 - 110 mg/dL .
A blood glucose level of 130 mg/dL indicates gestational diabetes, which can have adverse effects on the mother and the fetus.
The nurse should report this finding to the provider and initiate interventions such as dietary counseling, glucose monitoring, and insulin therapy if needed.
Choice A is wrong because WBC 7,000/mm³ is within the normal range for pregnant women, which is 4,500 to 10,000 cells/mcL .
A low WBC count would indicate an increased risk of infection, while a high WBC count would indicate inflammation or infection.
Choice B is wrong because hemoglobin 13 g/dL is within the normal range for pregnant women, which is 11 to 14 g/dL .
A low hemoglobin level would indicate anemia, while a high hemoglobin level would indicate dehydration or polycythemia.
Choice D is wrong because RBC 5.8 million/mm³ is within the normal range for pregnant women, which is 4.2 to 5.9 million/mm³ .
A low RBC count would indicate anemia or hemorrhage, while a high RBC count would indicate dehydration or polycythemia.
Correct Answer is A
Explanation
“I will turn all pot handles toward the back of the stove.” This indicates that the guardian understands how to prevent the toddler from pulling a pot off the stove and getting burned.
Choice B is wrong because a child’s car seat should be rear-facing until the child is at least 2 years old or reaches the maximum height and weight for the seat.
Choice C is wrong because the temperature of the water heater should be set to no higher than 120 degrees to prevent scalding injuries.
Choice D is wrong because drop-side cribs are banned in the United States due to the risk of entrapment and suffocation.
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